Job Description

Approved states per client: No exceptions. Must reside and hold a compact license in the following states: 
Colorado
Georgia
Indiana
Kentucky
Massachusetts
Minnesota
Mississippi
Ohio
Louisiana
Iowa
Washington State
Pennsylvania
Virginia

*Work from home – must reside in a state that is part of the Nurse Compact (multi-state-licensure) *

Education and experience needed for this role: 

• Nursing Diploma or associate's degree in nursing required.
• Bachelor’s degree in nursing strongly preferred.
• 3 years of clinical nursing experience in a clinical, acute/post-acute care, and community setting required.
• 1 year of case management experience in a managed care setting strongly preferred.
• Experience managing patients telephonically and via digital channels (mobile applications and messaging) preferred.
• Direct experience coordinating care as a case manager 

Certifications/Licenses required for this role: 

• Must have direct experience as an RN in one of the following: ICU, ER, Med Surg or Post Acute
• Current, active, and unrestricted Registered Nurse license required
• Certification in Case Management (CCM) required or to be obtained within 18 months of hire
• Certification in Chronic Care Professional (CCP) preferred

Essential responsibilities: 

• Lead the coordination of a regionally aligned, multidisciplinary team to provide holistic care to meet member needs telephonic and/or digitally.
• Use the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the members’ health across the care continuum.
• Assess the member's health, psychosocial needs, cultural preferences, and support systems.
• Engage the member and/or caregiver to develop an individualized plan of care, address barriers, identify gaps in care, and promotes improved overall health outcomes.
• Arrange resources necessary to meet identified needs (e.g., community resources, mental health services, substance abuse services, financial support services and disease-specific services).
• Coordinate care delivery and support among member support systems, including providers, community-based agencies, and family.
• Advocate for members and promote self-advocacy.
• Deliver education to include health literacy, self-management skills, medication plans, and nutrition.
• Monitor and evaluate effectiveness of the care management plan, assess adherence to care plan to ensure progress to goals and adjust and reevaluate as necessary.
• Accurately document interactions that support management of the member.
• Prepare the member and/or caregiver for discharge from a facility to home or for transfer to another healthcare facility to support continuity of care.
• Educate the member and/or caregiver about post-transition care and needed follow-up, summarizing what happened during an episode of care.
• Secure durable medical equipment and transportation services and communicate this to the member and/or caregiver and to key individuals at the receiving facility or home care agency.